Posted: March 21st, 2022

Comprehensive Annual Diabetes Visit HW 4

Comprehensive Annual Diabetes Visit HW 4

Incorporate appropriate psychosocial, cultural, health literacy, and family data into the management plan of a patient with type 2 diabetes. Apply evidence-based standards of care to the diagnosis, monitoring, and management of a patient with type 2 diabetes mellitus. Describe the barriers to coordination of diabetes care and systemwide improvements that could improve coordination of diabetes care. Describe the importance of an interprofessional team approach to the care of patients with diabetes. Describe the utility of the electronic medical record in the care of your practice population and in the reporting of quality measures. Educate a patient about type 2 diabetes with attention to and respect for the patient’s own disease model.


Comprehensive Annual Diabetes Visit

The American Diabetes Association (ADA) provides standards of care for diabetes management that are updated annually and can be downloaded to a smartphone. Clinician tasks for diabetes care:

Confirm the diagnosis and classify diabetes. Evaluate for diabetes complications and potential comorbid conditions. Review previous treatment and risk factor control in patients with established diabetes. Begin patient engagement in the formulation of a care-management plan. Develop a plan for continuing care.

See the American Diabetes Association’s “Components of the Comprehensive diabetes medical evaluation at initial, follow-up, and annual visits”: Part 1 (.jpg) | Part 2 (.jpg)

Electronic Medical Record

An electronic medical record system: Comprehensive Annual Diabetes Visit HW 4

Offers templates that increase the likelihood that patients will receive the recommended care. May improve the quality of care in primary care settings. Provides tools to evaluate patient care across an entire population. Allows documentation of improved physician performance, which may increase reimbursements by some insurers. Has been shown to interrupt the clinician-patient relationship—particularly via “screen gaze.”

Pathophysiology of Diabetes

Type 1 diabetes mellitus

The pancreas is damaged through autoimmune inflammation leading to destruction of the beta cells. The loss of beta cells leads to the complete inability to produce insulin, (immunologic etiology). Type 2 diabetes mellitus

The body is unable to recognize the insulin produced by the pancreas and use it properly (insulin resistance). Increased beta cell insulin secretion may initially compensate, but over time beta cells fail. Chronic complications

Both types of diabetes can cause the same end-organ damage. High blood glucose eventually affects blood vessels and therefore organs throughout the entire body. The heart, brain, kidneys, eyes, and the nerves that control sensation and autonomic function are affected. Remember: High blood pressure, which many patients with diabetes have, makes the vascular disease much worse.

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Diabetes: Common Manifestations of End-Organ Damage

Cardiovascular disease, including coronary heart disease, cerebrovascular disease, and peripheral arterial disease

People with diabetes are two to four times more likely to have heart disease or stroke than people without diabetes. Patients with diabetes who have a myocardial infarction have worse outcomes than patients without diabetes, and a diagnosis of diabetes is considered equivalent in risk to having had a previous myocardial infarction. Management of cardiovascular risk factors so commonly found in diabetes is therefore essential in preventing morbidity and mortality in these patients. The American College of Cardiology/American Heart Association ASCVD risk calculator (Risk Estimator Plus) is generally a useful tool to estimate 10-year ASCVD risk. These calculators include diabetes as a risk factor, since diabetes itself confers increased risk for ASCVD, although it should be acknowledged that these risk calculators do not account for the duration of diabetes or the presence of diabetes complications, such as albuminuria. Retinopathy

Diabetes is the most common cause of new cases of blindness among adults aged 18-64 years. Five years after diagnosis of type 2 diabetes, patients with more severe or uncontrolled disease that requires insulin have a 40% prevalence of retinopathy while those on oral hypoglycemic agents have a 24% prevalence. After 15 years of diabetes, almost all patients with type 1 diabetes and two-thirds of patients with type 2 diabetes have background retinopathy. By the time the patient’s vision is affected, substantial retinal damage may have already occurred. Proliferative retinopathy is prevalent in 25% of patients with 25 or more years of diabetes. In addition to optimizing glycemic control, optimizing blood pressure and serum lipid control can also slow the progression of diabetic retinopathy. Neuropathy

Neuropathy is a heterogeneous condition that is associated with nerve pathology. The condition is classified according to the nerves affected. The classification of neuropathy includes focal, diffuse, sensory, motor, and autonomic neuropathy. The prevalence of neuropathy defined by loss of ankle jerk reflexes is 7% at 1 year, increasing to 50% at 25 years, for both type 1 and type 2 diabetes. Nephropathy Comprehensive Annual Diabetes Visit HW 4

Nephropathy is common in diabetes: 20-40% of people with diabetes develop diabetic nephropathy. Diabetes was listed as the primary cause of kidney failure in 44% of all new cases in 2014.

Acute Diabetic Decompensations (DKA and HHS)

Type 1 diabetes

In patients with type 1 diabetes, without sufficient insulin, blood sugar runs high, and diabetic ketoacidosis (DKA) can develop. Type 2 diabetes

Patients with type 2 diabetes with hyperglycemia more often develop hyperosmolar hyperglycemic state (HHS). Typically it is the patient with type 1 diabetes who is most at risk for developing DKA; however, patients with type 2 diabetes can also develop DKA. This happens because, over time, type 2 diabetes starts to resemble type 1 diabetes as pancreatic function dwindles and patients with type 2 diabetes may begin to require insulin. If insulin deficiency is severe enough, a patient with type 2 diabetes may produce ketones and develop hyperglycemia. For example, an older adult patient with longstanding type 2 diabetes who becomes acutely ill with pneumonia could easily develop DKA.


HW 4 Comprehensive Annual Diabetes Visit
HW 4 Comprehensive Annual Diabetes Visit

HW 4 Comprehensive Annual Diabetes Visit

Incorporate relevant psychological, cultural, health literacy, and family data into a type 2 diabetes patient’s management plan. Use evidence-based standards of care to diagnose, monitor, and manage a type 2 diabetes mellitus patient. Describe the impediments to diabetic care coordination and systemwide improvements that could improve diabetes care coordination. Describe the significance of an interprofessional team approach to diabetes care. Describe the electronic medical record’s utility in the care of your practice population and in the reporting of quality measurements. With consideration and respect, educate a patient about type 2 diabetes.

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